Based on recommendations from the British Society of Gastroenterology (BSG) and National Institute for Health and Care Excellence (NICE), simplified into:

👉 what you actually need to organise in clinic or on discharge
👉 not long guideline documents

Because once a patient has cirrhosis, your job changes from:

❌ “treat the liver disease”
to
✅ “prevent complications and detect cancer early”

Surveillance is what prevents deaths.

✅ Why surveillance matters

Cirrhosis patients are at risk of:

Hepatocellular carcinoma (HCC)
Variceal bleeding
Ascites/SBP
Encephalopathy
Renal failure

Many of these are:
👉 silent until late

So we screen regularly.

✅ First principle

Think:

Every cirrhosis patient needs routine surveillance, even if they feel well.

Normal symptoms ≠ low risk.

🔴 1. HCC (liver cancer) surveillance – MOST IMPORTANT

This is the one you must never forget.

Cirrhosis = high HCC risk.

Early cancer is treatable.
Late cancer isn’t.

Who needs it?

👉 ALL patients with cirrhosis
(regardless of cause: alcohol, MASLD, hep B/C, autoimmune, etc.)

What to do?

Every 6 months:

Liver ultrasound
AFP blood test (optional but commonly used)

That’s it.

Simple.

Why 6 months?

Because:

cancers grow fast
yearly is too late
3 months unnecessary

So:
👉 6 months is the standard interval

Practical tip

When discharging:
👉 always check “next ultrasound booked?”

Very commonly missed.

🔴 2. Variceal surveillance (portal hypertension)

Prevents catastrophic bleeds.

Who needs OGD?

At diagnosis of cirrhosis:
👉 baseline OGD to look for varices

Then:

No varices

Repeat every 2–3 years

Small varices

Repeat every 1–2 years

Large varices

Start:

non-selective beta blocker (carvedilol/propranolol)
OR
band ligation

No routine surveillance only — needs treatment.

Practical ward thinking

If you see:
“Cirrhosis – never scoped”

👉 they need OGD referral

🟡 3. Routine blood monitoring

Done regularly in clinic/GP.

Usually every 6–12 months.

Check:

FBC
U&E
LFTs
INR
Albumin

Why?

Helps detect:

worsening synthetic function
decompensation
renal issues

Trends matter more than single results.

🟡 4. Vaccinations (often forgotten)

All cirrhosis patients should have:

Hep A
Hep B
Flu
Pneumococcal

Because infection risk is higher and outcomes worse.

Easy win. Often missed.

🟡 5. Lifestyle + prevention

Simple but important.

Advise:

alcohol cessation
weight loss (MASLD)
diabetes control
avoid NSAIDs
careful with nephrotoxic drugs

Prevents decompensation.

🔴 6. Watch for decompensation

Surveillance isn’t just tests — it’s recognising deterioration.

Red flags

Ascites
Encephalopathy
GI bleeding
Jaundice
AKI
Recurrent admissions

If present:
👉 urgent hepatology review

Not routine follow-up.

✅ Practical ward/clinic scenarios

Scenario 1

Stable alcoholic cirrhosis
→ 6-monthly US ± AFP
→ OGD schedule

Scenario 2

No varices on first OGD
→ repeat in 2–3 years

Scenario 3

Large varices found
→ beta blocker/banding
→ not just surveillance

Scenario 4

Missed ultrasound for 2 years
→ rebook urgently

Scenario 5

New ascites
→ decompensation
→ admission/workup, not routine clinic

✅ What juniors should check on ward round

For every cirrhosis patient, ask:

Last ultrasound?
Last OGD?
On beta blocker?
Vaccinated?
Any decompensation?

If you check these five things, you’re doing good hepatology care.

❌ Common junior mistakes

Forgetting HCC surveillance
Thinking “they look well so no scan needed”
Not arranging OGD
Ignoring vaccinations
Missing early decompensation
Discharging without follow-up booked

Most harm is from missed follow-up, not missed drugs.

✅ Simple memory rule

Cirrhosis = 3 things to remember

👉 Scan every 6 months
👉 Scope for varices
👉 Monitor bloods

Everything else is secondary.

✅ Take-home concept

Cirrhosis care is proactive, not reactive.
Regular surveillance prevents bleeds and cancer.

If you only remember ultrasound every 6 months, you’ll already save lives.